The STRAMA Point Prevalence Study 2003 and 2004 on hospital antibiotic use
STRAMA initiated in November 2003 a successful nation wide point prevalence study, PPS.
The objective of the study was to introduce a nation wide survey system for frequent
assessment of the use of antimicrobial agents in hospitals in relation to diagnose. The study
was repeated during a two-week period in November 2004. Identical protocols were used in
both studies. The performed studies in 2003 and 2004 present very similar results indicating
the validity of the method.
Data were collected at the hospital ward level through personal visits. A case record form was
used which included demographic data as well as the amounts and indications for
antimicrobial agents against bacteria and fungi.
Three principal areas of the antimicrobial therapy in the hospital setting have been identified
for further interventions. First, the duration of perioperative prophylaxis is too long. Secondly,
antimicrobials with narrow spectrum can be used in a higher degree in treatment of
community-acquired pneumonia in Sweden. Thirdly, the use of fluoroquinolones should be
restricted in several indications, especially in community-acquired cystitis in women.
Demographic data of the two studies are presented in Table 1. The studied population
approximates to 60% of all admitted patients in Swedish hospitals during one day.
Table 1. Demographic data, The STRAMA Point Prevalence Study 2003 and 2004.
PPS
2003 2004
Participating STRAMA-groups
19
18
(out of 21)
No. of hospitals involved
54
49
University hospitals
9
7
County hospitals
20
19
Local hospitals
25
23
No. of patients admitted
13,536 11,348
No. of patients treated
4,178 3,622
Percent treated
30,9% 31,9%
Patients treated at:
University hospitals
1,538 1,112
County hospitals
1,855 1,734
Local hospitals
785
776
Percent women treated
49,9% 49,9%
No. of children treated
266
192
Table 2 shows the therapy reasons for the antimicrobial therapy. Since one patient can have
more than one therapy reason the total percentage is higher than the percentage of treated
patients. Hospital acquired infection includes only those treated with antimicrobials.
Table 2. Therapy reasons for antimicrobial therapy in percent of all admitted patients.
2003 2004
Community acquired infection 17,0 18,0
Hospital acquired infection
9,2 9,4
Perioperative prophylaxis
4,6 4,5
Medical prophylaxis
1,7 1,9
The observation already made in the 2003 PPS of too long duration of perioperative
prophylaxis was observed also in 2004. Forty percent of therapies were longer than one day
compared to 47% in 2003.
The most frequently used antibiotic class for treatment is cephalosporins. Table 3 shows the
distribution of the used drugs in treatment and prophylaxis. Isoxazolyl-penicillin is the most
frequently used group for prophylaxis. The total amount of antimicrobials used for adults was
43.1 DDD/100 admitted patients in 2004 study.
Table 3. Most commonly used antimicrobials for adults in percent of DDD in treatment and in
prophylactic use.
2003
2003
2004
2004
Therapy Prophylaxis Therapy Prophylaxis
No. of DDD
4084
1000
3708
904
Cephalosporins
22
18
23
15
Isoxazolyl-penicillins
12
45
12
45
Fluoroquinolones
12
9
13
7
Broad-spectrum penicillins
10
4
10
4
Beta-lactamase sensitive pc
9
3
8
3
Imidazoles
5
7
3
7
Tetracyclines
5
3
5
4
Carbapenems
4
<1
5
<1
Analysis of different diagnoses showed over-use of broad-spectrum antimicrobials in
community acquired infections. In pneumonia broad-spectrum antimicrobials like
cephalosporins and tetracyclines were included in 52% of therapies and constituted 46% of
the given DDDs. The corresponding results for penicillins were 27% of the treatments and
34% of the DDDs, Figure 1.
45,0
Percent of given therapies
40,0
35,0
30,0
25,0
20,0
15,0
10,0
5,0
2003, No. 493
Others
J01MA
Fluoroquinolones
J01FF
Lincosamides
J01FA Macrolids
J01EE Cotrimoxazole
J01DH
Carbapenems
J01DA
Cefalosporins
J01CE Betalactamase
sensitive
penicillins
J01CA Broadspectrum
penicillins
J01AA
Tetracyklines
0,0
2004, No. 503
Figure 1. Distribution of antimicrobials in treatment of community acquired pneumonia,
percent of the total amount of therapies, PPS 2003-2004.
PPS 2003-2004
Antimicrobials, ATC5-group, used in treatment of community acquired cystitis in women
40,0
35,0
Percent of therapies
30,0
25,0
20,0
15,0
10,0
5,0
0,0
J01CA Broadspectrum penicillins
J01DA
Cefalosporins
J01EA
Trimethoprim
J01EE Cotrimoxazole
2003, No. 151
J01MA
Fluoroquinolones
J01XE Nitrofuran
derivatives
Others
2004, No. 163
Figure 2. Distribution of antimicrobials in treatment of community acquired cystitis in
women, percent of the total amount of therapies, PPS 2003-2004.
For treatment of urinary tract infections in women fluoroquinolones was the second largest
group of therapies, 33%, Figure 2, but only 26% of the amount in DDD. Pivmecillinam was
used in 36% of therapies but constituted 44% of the DDDs. The fluoroquinolone consumption
can be expected to be too high.
In assessment of the therapies 87% were considered as adequate empirical (60%) or adequate
directed (27%) treatments. Thirteen percent of the treatments were assessed with incorrect
dosage (3%), non-effective drug treatment (2%) or other deviations like use of too broadspectrum or too long treatment (8%).
Mats Erntell